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Patient

Treatment Note

Student Name: Stephanie Janecek, S/OT

Patient Name: XX

Number of minutes in session: 60 minutes

S: Pt was met in room while completing her morning hygiene routine and was agreeable to have student
lead intervention session as part of her fieldwork experience. Pt verbalized that she was felt she was
doing much better at donning her socks and shoes and that she was has not been getting dizzy when
moving from sit-to-stand.

O: Pt was seen in inpatient room for 6o minute OT session to address moderate cognitive impairment
and to improve ADL and IADL performance.

ADLs & IADLs: Pt demonstrated making her bed with set up of clean linens at bedside. Pt then sat at
bedside and donned socks and shoes Ily. Pt ambulated to dayroom Ily to complete safety awareness
task of recognizing hazardous situations with mod I required for increased time once every four pictures.
Pt was given skilled instruction on how to push herself up on armrests when moving from sit to stand on
her way back to her room.

A: Pt demonstrated increased functional mobility while ambulating around bed and increased dynamic
standing balance when securing fitted sheet on mattress. Pt showed an increase in dynamic sitting
balance when bending at the waist to don socks and shoes at bedside, pt recognized this improvement.
Pt demonstrated an increase in safety awareness throughout safety awareness activity. Pts functional
mobility from sit to stand is improving and pt reported no dizziness after moving from sit-to-stand at the
end of therapy session, which was consistent with pt statement on orthostatic hypotension. Pt would
benefit from continued safety awareness assessment and ADL/IADL intervention to increase potential
for return to independent living situation.

P: Continue to address ADL and IADL performance along with moderate cognitive impairment 1x/day for
60 minutes, everyday for one week until planned discharge. Next session therapist will assess UE and LE
dressing and grooming/hygiene routine.